Comments on SDSN draft report on Indicators for Sustainable Development Goals

(from Stan Bernstein and supported by Commonwealth Medical Trust (Commat))

From the perspective of the SRHR community, the SDSN recommendations leave much to be desired. Sexual and reproductive health are included in several places but with formulations that do not give it much priority or coherence. For example, the realization of sexual and reproductive health rights are seen as instrumental to voluntary fertility decline “in countries above [3] children per woman” and relevant for the continuation of voluntary fertility reduction in countries above replacement level fertility in their statement of Target 2c. This does not capture the breadth of SRH concerns and the universality of rights in this area (especially to make voluntary and informed choices about the number, timing and spacing of one’s children) independent of fertility levels. SRH is also recognized as a component of “universal coverage of quality health care”. Other elements of women’s empowerment (including gender based violence) and health (maternal mortality ratios and rates) are included elsewhere and some links to other elements of economic and social development and environmental sustainability are noted. But there is a diminution of status relative to the independent MDG target 5B. However, the goal and target levels are considered to be frozen. (Comments/complaints are unlikely to be productive, but may be useful to stake a claim against that freeze in later discussions.)

In such a circumstance, improvement in the incorporation of SRH indicators can nonetheless be attempted and recommendations for the accompanying metadata describing the indicators, their rationales and possible national level additional monitoring can be made (though attention to metadata is not likely to impact policy priorities.)

Within these constraints, several issues deserve some priority:

Indicators related to poverty must be sex disaggregated and a place to capture the sex of the head of the household in poverty measures (with age and location details) should be found.

The overall recommendation is made for disaggregation of statistics with explicit citation of sex and location but dimensions of disaggregation are sometimes included in indicators and otherwise excluded. The first area of critical relevance is under the first Goal (“Achieve Development within Planetary Boundaries”) , Target 01a. End Extreme Poverty. The second indicator (pg. 36) cites the issue of measuring “Extreme multi-dimensional poverty” with an indicator still to be developed (under the lead of World Bank and the UN Statistics Division). Communications could be sent to the SDSN input site to call for special consideration of gender issues (e.g., female heads of household) and incorporation of SRHR issues under coverage of basic health services (line 24).

Page 50: Contest the expression of Target 2C . Lines 24-28 cites Paragraph 13 of ICPD PofA (a curious reference that needs proper specification) “highlight the importance of reducing population growth through voluntary transition to lower fertility levels, while respecting the rights of women to decide when and how many children they would like to have”. This makes the growth decline primary and rights subsidiary. The Cairo paradigm shift recognized that respecting the latter obtains the former.

Page 51: The restriction of the discussion (and current surveying) to ‘reproductive ages’ misses the need to assess the situation of sexually active younger women. Further, the monitoring framework for Every Woman Every Child uses “met need for family planning” (aka Proportion of demand satisfied) as a key indicator. This should be paired in the current document with the unmet need indicator (unmet need for family planning and proportion of demand for pregnancy delay or avoidance satisfied). The standard nomenclature might be adjusted to “unmet need for contraceptive services”, but this should not come at the cost of recognizing alternatives to modern methods (including improved approaches to periodic abstinence) as part of the standard monitoring. In any event, in most of the developing world the preponderance of family planning use involves modern methods.

Page 52: The Adolescent Fertility section suggests using the percentage of teenage girls who get pregnant. MDG indicators use age specific fertility rates (ASFR) for 15-19 year olds. There was a history during the adoption of this MDG measure that examined alternatives (proportion of 20-24 year olds who gave birth before age 18; age at birth of first child; etc.) before selecting the more readily available ASFR. The SDSN document contains several references to reports by 20-24 year olds on early (pre-18 years old mothers) births. This indicator, when used, is selected to avoid data truncation (from asking the age of first birth of women still in the 15-19 year age group), however, this indicator includes a built-in time lag that complicates early programmatic relevance and monitoring.

The indicator framework has a Goal 3 “Ensure Effective Learning for all Children and Youth for Life and Livelihood”. This includes Target 03b (pg. 55ff). All girls and boys receive quality primary and secondary education that focuses on a broad range of learning outcomes and on reducing the dropout rate to zero.” Under this rubric, special attention is given to literacy and numeracy. A call can be made directly include any or all of comprehensive sexuality education (CSE)/ life skills training/family life education/gender-sensitive training and metadata in the supplementary materials.  The current formulation of preference is CSE, but “Life Skills Training (including literacy, numeracy, gender sensitivity and sexual and reproductive health and rights)” might be more politically persuasive.

Goal 4 (pg. 61ff) is entitled “Achieve Gender Equality, Social Inclusion and Human Rights”. The first Target addresses “Monitoring and Ending discrimination and inequalities …” and includes as a first indicator “Birth registration”. This can be widely endorsed. However, other demands for better monitoring, compliance and accountability require attention. The improvement of HMIS records and expansion of mHealth approaches (including Epi-Surveyor approaches to data capture) should be explicitly incorporated as it relates to a wide variety of service statistic based indicators. Similarly, attention needs to be given to ensuring the regularity and quality of census and periodic survey efforts (including the expansion of DHS and MICS programs). In the area of sexual and reproductive health, inclusion of sexually active women not married or in union should be standard (where feasible and relevant, expansion of sampling frames to include sexually active 10-14 year olds should also be given some priority).

Target 4c (pg. 67f) addresses “Prevent and eliminate violence against individuals, especially women and children.” It includes as indicators women subjected to violence within the last year by an intimate partner and the percentage of referred cases that are investigated and prosecuted. Some specific attention to harmful traditional practices (e.g., FGM/C, violence against sexual minorities) should be proposed. The restriction to “intimate partner violence” (pg. 67, Indicator #32) reflects current measurement practice. Some attention to other, particularly sexual, violence would be welcomed.

Under Target 05a for universal coverage of quality healthcare (pg. 69ff) attention should be given to ensuring  that basic primary health services includes family planning and whole range of additional reproductive health needs (delivery, HIV/AIDS prevention, post-abortion care, safe abortion where permitted by law). Attention should also be given to suggesting that the operationalization of this measurement captures both the proportion of the population with some minimal package [to be specified] and the proportion with access to a more complete package.  It might be proposed as well that national frameworks for monitoring include the major contributors to various measures of health burdens through the life cycle, reflecting local contributions to the total burden of disease and to opportunities to promote positive health.

Page 69 Indicator 34: We must ensure inclusion of universal access to SRH among the elements monitored. The explanation in the document is based on physical access (proximity) and financial affordability, with a normative standard used for EmOC. A more comprehensive criterion relates to AAAQ (access, affordability, acceptability and quality).  A technical quality component (availability of necessary equipment/drugs and commodities) is included only as an “additional indicator countries may consider” pg. 71 lines 24-29. But some additional indicators of service quality and acceptability should be incorporated in the development of such an indicator. Concerning the quality dimension, as observational data is difficult to obtain and standardize, the availability of systematic checklists incorporating appropriate standards of care might be a useful proxy. The acceptability criterion is separate monitored (in DHS reporting) via reports of reasons for non-use; it also reflects the quality of counseling.

Related to this indicator (and relevant to providing one element of structure to the list of additional national indicators on page 71ff) would be a composite indicator capturing the proportion of the population (with relevant disaggregation by age, sex, location and wealth) getting services across the full continuum of care for reproductive, maternal and newborn health (i.e., family planning, antenatal care, skilled birth attendance, availability of EmOC, post-partum care [counseling on breast-feeding, immunizations, family planning], exclusive breast-feeding for 6 months and selected early immunizations). Such a measure could mitigate the silo-ing of individual interventions and further promote integrated voucher schemes and conditional cash transfers that include SRH components.

Indicator 37 (page 71, lines 4-8), as it is developed, should be reviewed to ensure it captures mental health concerns related to reproductive health within its operationalization (including, e.g., severe post-partum depression and depressive and phobic responses to sexual and gender-based violence and to stigmatization of sexual minorities and persons living with sexually transmitted infections). In this regard, the metadata should also include (after line 21) a cross-reference to the relevance of Target 4C (Prevent and eliminate violence against individuals, especially women and children).

The proposed Target 5b (pg. 74) relates to ending preventable child and maternal deaths and deaths due to non-communicable diseases. The proposed Indicator 38 captures neonatal, infant and under-five mortality rates. In the document, neonatal mortality is included both here and in “additional indicators” (pg. 77). The neonatal mortality rate should properly be captures by Indicator 38. A useful supplementary indicator (for the latter section) would monitor spacing between the most recent and the preceding birth (inter-birth interval). The evidence clearly points to heightened risk of neonatal mortality after short birth intervals (operationalization might assess the proportion of inter-birth intervals shorter than 24 months).  In this section, it would be useful for a supplementary indicator (to Maternal mortality ratio and rate) to capture the proportion of maternal deaths due to unsafe abortion.

Integration of services is an issue ill-treated in the current SDSN proposal. There is no recognition of synergies between different health efforts (no less, between women’s education, empowerment and health outcomes). Supplemental indicators for Target 5A include coverage of PMTCT services for HIV+ women (pg. 72, lines 24-28) and Indicator 41 (pg. 75 lines 26-42) captures HIV prevalence, treatment and mortality. A useful supplementary indicator would capture the proportion of HIV+ women who are assessed for their fertility intentions and, subsequently, referred for or provided contraceptive services. Care should be taken to ensure that such systemic responses reflect the rights of these women to informed and voluntary choice. Additional assessment (at national level, if not in the overall framework) of the consistency and effectiveness of referral systems and integrated service delivery would be welcomed.

Target 5C (pg. 78f) contains only items related to obesity, tobacco and alcohol within the rubric of addressing unhealthy behaviors. This is consistent with an emphasis on NCDs (non-communicable diseases). However, little attention is given in the current framework (though clearly an issue of unhealthy behaviors) to unhealthy sexual behavior (e.g., condom use with last non-regular partner; number of partners within a specified time).

Target 5C (pg. 78ff) focuses on NCDs, with particular attention to diet, physical activity, tobacco and alcohol use.  Most of the disease burden related to sex and reproduction are properly captured in other targets and indicators. But this section must address sex and age variation. Data shows that as much as 2/3 of later disease results from habits started in adolescence.

Further details will be elaborated in a personal communication to SDSN. Additional concerns should be raised by the community at large.